Wednesday, January 20, 2021

Clinico-social-case format (Family details)

Identification and Family data/ General identifications:

Family details:

Name of the village/ city-

Nearest health center-

Type of the family:

Nuclear/ Joint/ 3 Generation

Composition of the family:

Total number of family members=

Head of the family (name):

Address & area map:

(Write the complete address & draw the area map from the main road to the nearest PHC/ Sub center and the house where the case has to be taken)

Elevation of the house:

(Draw frontal view of the house)

Cross-sectional plan of the house:

(Draw cross-section of the house)

Habituated since: ____________(duration in years/ months)

Migrated....yes/ no

If migrated then 

Migration details:

Migrated from:________________(name of the place)

Duration:__________

Reson for migration:_______________________

Nationality: Indian/ ___________________

Family structure:



Socioeconomic status:

According to ____________(Name of the classification)

Per capita monthly income

= Total family income/ Total no. of family members

Above/ Below poverty line

Having APL/ BPL card: Yes/ No

Colour of the card:_________________

Approximate expenditure of the family per month:

Food: Rs__________

Housing: Rs_____________

Clothing:Rs____________

Education:Rs_______________

Ceremonies:Rs_________

Medical care:Rs_______________

Recreation:Rs_____________

Others:Rs______________

Total expenditure: Rs___________________

Savings: Total monthly income- Total monthly expenditure

=_____________(Increasing/ Decreasing/ Satisfactory)

Debt: Yes/ No     (Increasing/ Decreasing/ Satisfactory)

Privileges: 

Yes/ No

Financial benefits from the government: Yes/ No

Old age/ Handicap/ Widow pension: Yes/ No

Health insurance benefits from the government: Yes/ No

If yes list them____________________

______________________________________________

Utilization of social & health services: Yes/ No

If yes list them___________

______________________________________________

Vital events in the family:

Family health study:

Health problems in other family members: Yes/ No

Immunization status of the family members: ___________

Housing and Environment:

House:

Area: Urban/ Rural/ Slum

Tenure: Own/ Rented

Type of the house: Pucca/ Katchcha/ Semi-pucca

Set back: Adequate/ Inadequate/ Nill

Attachments: Side to side/ Back to back/ Both/ Nill

Roof: Concrete & cement/ RCC/ Tile/ Zinc sheet/ Thatched/ Others

Floor: Cement/ Mud/ Stone/ Others

Construction safety: Yes/ No

Spatial space (height): Sufficient/ Insufficient

Living space (rooms): Adequate/ Inadequate

Overcrowding: Present/ Absent

Doors & window space: Sufficient/ Insufficient

Ventilation: Adequate/ Inadequate

Cross-ventilation: Present/ Absent

Natural light: Adequate/ Inadequate

Artificial light: Adequate/ Inadequate

Lightening (with artificial light): Adequate/ Inadequate

Dampness: Present/ Absent

Appliances: Refrizator/ Washing machine/ TV/ Others_______

Bathroom: Separate/ not separate 

Bathroom drainage: Hygienic/ Non-hygienic

Mosquito breeding: Yes/ No

Fly breeding: Yes/ No

Potential mosquito breeding areas: Present/ Absent

Potential fly breeding areas: Present/ Absent

Cattle: Present/ Absent

If yes distance of cattleshed from the living room________m

Cleanliness of the premises: Clean/ Unclean

Surroundings of the house: Water collection-Yes/ No, Children excreta-Yes/ No, Dogs-Yes/ No, Poultry-Yes/ No, Pig-Yes/ No, Rats-Yes/ No

Inside the house: Rodents-Yes/ No, Cockroaches-Yes/ No, Snakes-Yes/ No, Scorpion-Yes/ No, Pets-Yes/ No, Poultry-Yes/ No, Cattle-Yes/ No

Kitchen: 

Situated: Separately/ With a living room

Cleanliness: Clean/ Unclean

Space: Spacious/ Congested

Floor-type: Katchcha/ Pucca

Light: Adequate/ Inadequate

Ventilation: Adequate/ Inadequate

Storage of cooked food: Outside/ Refrigerator/ Closed/ Open

Storage of uncooked food: In jute bags/ Plastic containers/ Aluminum containers/ Mud-made containers/ Earthen pots

Fuel used: LPG/ Biogas/ Coal/ Wood/ Cowdung cakes

Chulha used: Smokeless/ Smoke letting

Smoke outlet/ Exhaust: Present/ Absent

Drainage: Open/ Closed

Facilities for washing utentils: Present/ Absent/ Inside/ Outside

Water supply:

Source of drinking water: Public/ Private/ Well/ River/ Borewell

Supply: Intermittent/ Continuous

Source of water for other purposes: Same/ Other_________

Storage of drinking water: Overhead tanks/ Buckets/ Bottles/ Others

The distance of walk to get water (If needed to carry): _________

Method of drawing out water for drinking from the container: Hygienic/ Unhygienic 

Purification of water: Done/ Not done

If done, then method of purification: Boiling/ Filtration/ Chlorination

Evidence of mosquito breeding in stored water: Yes/ No

About of water used per day by the family:_________Litres

Refuse/ Waste disposal:

Storage inside the house: Hygienic/ Unhygienic 

Disposal outside the house: Hygienic/ Unhygienic 

Frequency of disposal: Daily/ Weekly/ __________

Latrine:

Present/ Absent/ Own/ Shared/ Community type

Space: Adequate/ Inadequate

Water availability: Present/ Absent

Type of latrine: RCC/ Borehole/ _____________

Toilet maintenance: Hygienic/ Unhygienic 

Wastewater disposal: Hygienic/ Unhygienic 

Lightening: Adequate/ Inadequate

Social/ Psychosocial environment:

Any cause of psychosocial stress: Yes/ No

The family generally accepted by the community: Yes/ No

Relation with family members & neighbours: Good/ Not good

Personal hygiene of the family members: Satisfactory/ Not satisfactory.

Custom & health practices:

System of marriage_______________

Usual age of marriage for boys____________years

Usual age of marriage for girls__________years

Average expenditure on marriage___________

Dowry prevalent in society:  Yes/ No

Any other significant custom___________

Maternal & child health practices: 

Pregnancy: Special diet- Yes/ No, physical activity-Yes/ No, ANC -Yes/ No, Any other significant practicpractice ________

Lactation: Special diet- Yes/ No, physical activity-Yes/ No, ANC -Yes/ No, Any other significant practicpractice ________

Child-rearing practices: 

Special practices such as oil bath & Kajal application-Yes/ No

Usual time of commencement of breastfeeding___________

Colostrum is given- Yes/ No

Artificial milk has given during breastfeeding-Yes/ No

The usual age for starting of weaning_______months

The usual weaning foods______________________

Attitude towards childhood immunization: __________

Health practices:

System of medicine preferred: Allopathy/ Ayurved/ Homeopathy/ __________________

Medicines taken from_________________________

Knowledge, attitude & practices towards common illnesses: _______________________________________________

KAP regarding contraception:

The knowledge that births can be planned-Yes/ No

If yes then what are the methods known-__________

Do they know from where to avail services for contraception-Yes/ No

Which method___________________________

If no, then why not_____________________________

No of eligible couples in the family___________

Dietary assessment of the family:


References:
  1. https://www.nin.res.in/downloads/DietaryGuidelinesforNINwebsite.pdf
  2. https://www.researchgate.net/figure/A-sketch-map-left-with-its-corresponding-metric-map-generated-from-OpenStreetMap_fig1_262372321 photo credit
  3. https://in.pinterest.com/pin/395964992229178838/ photo credit
  4. https://cadbull.com/detail/153045/AutoCAD-House-Building-Cross-Section-Drawing-DWG-File photo credit

No comments:

Post a Comment

Seminar: Cohort study design